Provider Demographics
NPI:1790902658
Name:MARTIN, AUDREY BETH (MFT)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:BETH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5605 OCEAN VIEW DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1532
Mailing Address - Country:US
Mailing Address - Phone:510-428-1505
Mailing Address - Fax:510-898-0934
Practice Address - Street 1:5605 OCEAN VIEW DR
Practice Address - Street 2:SUITE 5
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1532
Practice Address - Country:US
Practice Address - Phone:510-428-1505
Practice Address - Fax:510-898-0934
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23054106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist